One million success stories. Start yours today.

Clinical Documentation Improvement Specialist

Date Posted: Apr 19, 2026
Hourly: $30.00 - $60.00
Apply Now

Job Detail

  • location_on
    Location Pittsburgh, Pennsylvania
  • desktop_windows
    Job Type: Full Time
  • schedule
    Shift: First Shift (Day)
  • analytics
    License: Clinical Documentation Specialist
  • group
    Positions: 2
  • calendar_view_day
    Experience:
  • male
    Gender: No Preference
  • school
    Education:
  • home_health
    Facility: Staffing
  • calendar_month
    Apply Before: May 21, 2026
Email to Friend Add to Favourite Report Abuse

Job Description

Job Summary

The Clinical Documentation Specialist (CDS) collaborates with physicians and the healthcare team to enhance the accuracy, completeness, and specificity of clinical documentation. Through concurrent review and real-time engagement, the CDS ensures appropriate capture of patient severity, supporting accurate representation of services provided for all inpatient encounters.

Key Responsibilities

  • Support organization-wide Clinical Documentation Improvement (CDI) initiatives and best practices
  • Collaborate with physicians and care teams—both in person and through formal queries—to clarify incomplete, conflicting, or ambiguous documentation
  • Promote accurate documentation that reflects severity of illness (SOI), risk of mortality (ROM), and overall clinical complexity
  • Develop and present trending data and performance insights to physicians individually and in group settings
  • Apply knowledge of complications, comorbidities (CC/MCC), DRG assignment, and procedural impact to guide documentation improvement efforts
  • Conduct daily, concurrent reviews of inpatient medical records, including physician documentation, diagnostics, labs, and treatment plans
  • Evaluate and monitor documentation practices across the medical staff to ensure compliance and accuracy
  • Educate providers and clinical staff on documentation standards, regulatory requirements, and reimbursement implications

Qualifications
  • One of the following required:
    • Minimum of three (3) years of acute care clinical experience (medical/surgical required; critical care preferred) with working knowledge of DRGs
    • RHIA or RHIT credential with at least three (3) years of experience in Prospective Payment Systems (PPS) and DRG assignment
    • Demonstrated expertise as a consultant in medical coding and DRG assignment
  • Prior CDI experience strongly preferred
  • Solid understanding of DRG methodology, quality metrics, and utilization review processes
  • Proficiency with electronic health records (EHR) and clinical documentation systems
  • Strong analytical, communication, and interpersonal skills with the ability to engage physicians professionally and diplomatically

Licensure, Certifications & Clearances

  • One of the following credentials required:
    • Certified Coding Specialist (CCS)
    • Registered Nurse (RN)
    • Registered Health Information Administrator (RHIA)
    • Registered Health Information Technician (RHIT)
    • Certified Registered Nurse Practitioner (CRNP)
    • Doctor of Medicine (MD)
    • Doctor of Podiatric Medicine (DPM)
  • Act 34 clearance required (where applicable)
  • Must hold a current license in the state of practice or a multistate license under the Nurse Licensure Compact (NLC), if applicable
    • Employees relocating to a new state must apply for state licensure within 60 days of establishing residency
 
 

Benefits

 
 

Skills Required

Company Overview

Caregivax.com
Chandler, Arizona
13 Current Jobs Openings

At Caregivax.com, we are committed to connecting outstanding healthcare professionals with organizations that value their skills, dedication, and expertise. As a trusted healthcare staffing and recruiting agency, we specialize in placing qualified Nu... Read More

Related Jobs

    There are currently no open positions available.

    Search Jobs
Quick Links
Jobs by License Type
Jobs by Facility Types
Contact Us
Phoenix, Arizona
Copyright © 2026 CareGivax. All Rights Reserved.
Powered by Nekston